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Is ultrasound a feasible tool to verify endotracheal tube position in neonates?

2012; Elsevier BV; Volume: 84; Issue: 1 Linguagem: Inglês

10.1016/j.resuscitation.2012.09.026

1873-1570

María Mora-Matilla, Paula Alonso‐Quintela, Ignacio Oulego‐Erroz, Silvia Rodríguez‐Blanco, Sandra Gautreaux-Minaya, D. Mata Zubillaga,

Neonatal Respiratory Health Research

Tracheal intubation (TI) is a common procedure in neonatal intensive care unit. Esophageal intubation may occur depending on operator's experience and clinical setting (e.g. during resuscitation) with significant morbidity. Clinical signs alone are not reliable to confirm endotracheal tube (ETT) position and a secondary method is needed. Capnography is mostly used. However, it is not 100% accurate and may yield false negative results in case of low pulmonary blood flow during cardiopulmonary arrest1Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation.J Emerg Med. 2001; 20: 223-229Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar. Chest radiography is usually performed after TI to discard misplacement of ETT, mainly right mainstem intubation (RMI). Ultrasound is an alternative and complementary method that may permit both verification of TI and ETT insertion depth2Kerrey B.T. Geis G.L. Quinn A.M. Hornung R.W. Ruddy R.M. A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal tube position in a pediatric emergency department.Pediatrics. 2009; 123: e1039-e1044Crossref PubMed Scopus (76) Google Scholar, 3Oulego-Erroz I. Alonso-Quintela P. Rodríguez-Blanco S. Mata-Zubillaga D. Fernández-Miaja M. Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant.Resuscitation. 2012; 83 ([Epub 2012 March 2]): e143-e144Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar. We checked ETT position with ultrasound and capnography during 10 intubations in 7 newborns. Patient's weight and gestational age ranged from 530 to 3150 gram and 24–40 weeks respectively. All patient were intubated for respiratory distress and were in a stable hemodynamic condition. A 8 Hz microconvex probe was placed in the longitudinal (L) and transversal (T) planes above the supraesternal notch during insertion of ETT. TI was confirmed if ETT was clearly identified within the trachea immediately posterior to anterior tracheal wall in L and a characteristic comet tail artefact arising from ETT surface was seen in T4Milling T.J. Jones M. Khan T. et al.Transtracheal 2-d ultrasound for identification of esophageal intubation.J Emerg Med. 2007; 32: 409-414Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar (Fig. 1). After intubation, the patient was bagged and the ultrasound probe was placed in the thorax to check the presence of lung sliding sign (LSS). A bilateral LSS indicates correct TI while unilateral right LSS indicates RMI. After intubation radiography was performed. The time to perform ultrasound and radiography was recorded. Capnography was positive in 7 cases and negative in 3 (4 intubation attempts needed in the same patient). Ultrasound identified correct ETT only in the 7 intubations with positive capnography. Bilateral LSS was present in all patients. A correct ETT insertion depth was observed also in radiography in all cases. Ultrasound exam was performed in an average time of 45 s compared to the 21 min needed to perform and visualize chest radiography. This preliminary experience indicates that ultrasound may be a feasible and useful method to check TI and ETT position in newborn. Verification of TI and confirmation of ETT position are novel uses of ultrasound in neonates. We firstly describe it in a preterm newborn in severe cardiorrespiratory compromise3Oulego-Erroz I. Alonso-Quintela P. Rodríguez-Blanco S. Mata-Zubillaga D. Fernández-Miaja M. Verification of endotracheal tube placement using ultrasound during emergent intubation of a preterm infant.Resuscitation. 2012; 83 ([Epub 2012 March 2]): e143-e144Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar. Ultrasound may have advantages for verification of TI when absent or low pulmonary blood flow may cause a false negative result of capnography with important implications1Li J. Capnography alone is imperfect for endotracheal tube placement confirmation during emergency intubation.J Emerg Med. 2001; 20: 223-229Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar. However, outside from these circumstances capnography seems a better option. In our opinion the actual benefit of ultrasound is the potential to avoid the routine use of radiography to check ETT position. Dennington et al. have shown that ultrasound has a good correlation with radiography to identify ETT tip in considerable less time5Dennington D. Vali P. Finer N.N. Kim J.H. Ultrasound confirmation of endotracheal tube position in neonates.Neonatology. 2012; 102: 185-189Crossref PubMed Scopus (63) Google Scholar. Our results are in the same direction although using different techniques. In addition, ETT may displace at any moment; ultrasound can be repeated as needed without exposing the baby to unnecessary radiation. In conclusion, ultrasound seems a feasible technique to verify TI and confirm ETT position in newborn. Further research is needed to validate its use in clinical practice. The authors have no conflict of interest to declare.